HomeMy Public PortalAbout5106 SULTANA AVE_Sewer__ .:QAeett 88 APPLICATION FOR PERMIT
DIVISION OF BUMDING AND SAFETY SEWER-SEWAGE DISPOSAL 1
Department of Comfy Engineer
County of Lm Angadtw BUILDING
JOHN A L-AMBIE COUNTY ENGINEER ADDRESS L 16
m CASSATT D GRIFFIN SUP T OF BUILDINO LOCALITY `
FOR APPLICANT TO FILL IN CROSS ST
LEGAL _
DESCRIPTION LOT NO -3 OWNER
MAIL
BLOCK TRACT ADDRESS
NO OF SLUGS CI TEL NO
SIZE OF LOT NOW ON LOT
USE OF
BUILDINGS DISTRICT NO GROUP
YAP
BK PG
CONTRACTOR �
ADDRESS CONNECTION DATA
t STATION DEPTH
CITYEL NO
3 MANHOLE REFERENCE , UPPER
STATE LOWER
Ell 8TRATION NO ❑ COUNTY
No DESCRIPTION OF WORK FEE
HOUSE SEWER CONNECTING TO TYPE OF CONNECTION LENGTH FROM
PUBLIC SEWER $3 SO Y CURB P L Y L TO P L
SEPTIC TANK,SEEPAGE PIT OR O D
PITS AND/OR DRAINFIELD ® S 9 00
OVERFLOW SEEPAGE PIT DRAINFIELD CO IVP NO JPC No
B NO
EXTN CESSPOOL DRYWELL MANHOLE $200 O
HOUSE SEWER CONNECTING TO
PRIVATE DISPOSAL SYSTEM C $I 00 TRUNK PERMIT NO ROAD PERMIT NO
CONKECTABDITIWORK TO HOUSE SEWER LD6 OP $1 00 STATE ENCROACHMENT
PERMIT NO
ALTER REPAIR OR ABANDON HOUSE INDUSTRIAL
SEWER OR DISPOSAL SYSTEM ® 1 00 WASTE APPROVAL
CHARGES
CONNECTION CHARGE FEE
OWNERS PEHMIT s 1 00
AUTHORIZATION TOTAL MO REIYBURSEM ENT FEE.
1 HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON- APPROVALS' DATE INSPECTOR SSI GNATURE
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING DWELLING
TO THE PUBLIC SEWER NEW HOUSE SEWER / 0
SIGNED THIS DAY OF 19_ CONNECT ADDITIONAL
OWNER OR BUILDING OR WORK A
OWNERS AGENT SEPTICTANK SEEP,PIT(S)
ADDRESS ANO/OR DRAINFIELD (e
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION CE98POOL❑ DRYWELL❑
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR SEWER OR
PLUMBING AND SEWERS SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON CT PLUGHOUSE AND
CALIFORNIA OR THAT I AM THE LEGAL OWNE OF THE ABOVE
DESCRIBED RESIDENT PROP • BACKFILL SEPTIC TANKS El
SIGNATURE SEEP PITS) ❑ CESSPOOLS❑
OF PERMITTEE
JOHN A LAMBIE COUNTY EN NEER ^yALIDATION ROBERT A WOOD CHIEF PL-BG INSPECTOR
�rU2 6 3 1 A FEB 7 4 5.0 O o
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